This Podcast is superseded by Version 2, but there still is an enormous amount of foundational teaching here
Intubation Checklist V. 2
Checklists
Since Peter Pronovost's landmark study on how a simple checklist can nearly abolish central line infections, checklists have been the darling of the medical literature. But central lines generally are for elective procedures, allowing us the time and patience to run through the list. Can we gain the same safety and cognitive benefits in an adrenaline-laden procedure like intubation? Hell yeah!
It all starts with the EMCrit Intubation Checklist
The Components
HOp Killers
Here is the wee on the HOp Killers: Hemodynamic Kills, Oxygenation Kills, and pH Kills
- Intubating the Hemodynamically Unstable Patient
- Intubating the Patient at Risk for Critical Hypoxemia
- Intubating the Patient with Metabolic Acidosis
RSI or Awake? · DSI? · RSA? · ICP/Vascular?
- Awake Intubation Lecture
- More info on Delayed Sequence Intubation (DSI)
- Rapid Sequence Airway (RSA)
- ICP/Vascular Intubation
Are the peri-intubation medications ready?
Push-Dose Pressors
What is the plan for unexpected difficult or failed airway?
- I use a modified version of the Shock Trauma Center Failed Airway Algorithm
- Cook Gas ILA (My preferred Extraglottic Airway)
Can the cricothyroid membrane be palpated?
What is the plan for post-intubation sedation?
- A bad sedation package traps your patient in a nightmare
Is the patient positioned adequately?
Would the patient benefit from pre-intubation NGT?
Skills of Intubation
Laryngoscopy
Video Laryngoscopy
Here are some tips
Cricothyrotomy
See this post for all things surgical airway
Post Intubation Management
Building Checklists
Other People's Intubation Checklists for Inspiration
The EMCrit checklist drew inspiration and aid from these other checklists. Shoulders of giants and such…
List of all Difficult Airway Equipment Extant
Did you like this post? Then tweet the hell out of it
Finally… The EMCrit Call/Response VodCast is done. Podcast 92: http://t.co/0PJbSFQ2 Now tear it apart and make it better!
— the EMCrit Crew (@emcrit) February 5, 2013
Additional New Information
More on EMCrit
EMCrit 176 – Updated EMCrit Rapid Sequence Intubation Checklist(Opens in a new browser tab)
Additional Resources
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Professor
Nassau University Medical Center
No conflicts of interest (coi).
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Scott, amazing work. We’re in your debt. The plan jargon makes great sense of hardcore Emcriters – but wondered if there was a way to make the planing list intuitive to those not yet converted. I tried putting it into a flow diagram for you to look at. How can I send it? tim
Happy to look, but the jargon is all explained on the back. Upload to yousendit.com and send to emcritpodcast at gmail
Scott, I love the checklist, I think its a great reminder to everyone. I think an important thing to mention is that the 0 PEEP in the COPDer and asthmatic may be reasonable, at least initially, but often times the auto-PEEP makes triggering of the ventilator more difficult. The patient needs to create an inspiratory effort to overcome the positive alveolar pressure that occurs due to auto-PEEP. Therefore, the patient will be incredibly uncomfortable on the vent unless paralyzed/heavily sedated. It’s not uncommon to see the patient actually breathing 30, but when looking at the vent they are AC 12,… Read more »
Dave, These are initial vent settings; during the first few hours after intubation for asthma the pt should not be triggering at all. They should be profoundly deeply sedated. In the later stage, all PEEP will do is allow triggering, not reduce the work of breathing (just as you mention). If the pt is spontaneously breathing, PEEP is fine just as you say.
Hello Scott A little strange to reply on a comment from eight years ago. I’m just getting to know this website. Great stuff btw! I’m also a little confused by the PEEP 0 is asthma or COPD. If the patiënt is at risk for auto-PEEP, I always learned and noticed that increasing the PEEP will paradoxically improve the ventilation. The reason for this was that the pressure distal to the narrow airway will also increase, what will help the airflow coming from the alveolae to the bronchus. So my first reaction with patients with auto-PEEP would be to start with… Read more »
thanks Scott!
My suggestions
Print it on a T shirt, front and back
Make an app with it
build it into common patient monitors as an electronic checklist
we are not worthy sir
you be the man
Thanks Brother Minh!!
My physics teacher in high school had this shirt: http://www.flinnsci.com/store/Scripts/prodView.asp?idproduct=15728
favorite physics formulas. note: printed upside down, so wearer can read
airway scrub tops w/ checklist upside down on front, rightside up on back
Seth and Minh I think these t-shirt ideas are awesome. Might suggest having an ATLS/ACLS shirt with algorithms on front and on back something like “Follow me I am the Code Leader”. In undergrad the Geography Deptartment had shirts on the back that said, “Follow me I am a Geographer”.
Hey Scott,
Awesome work, a true culmination of almost half of your podcasts to date.
It’s hilarious that half the acronyms were coined by you, so it only makes half as much sense to the non EM-critters out there.
One suggestion for the team portion is giving specific instructions to your in-line stabilizer for the collared patients, so that they know exactly what they are doing.
Cheers,
Chris
Will add emphasis to that on the back, great point
Along the lines of Minh.
Print it, laminate it, and zap-strap it to the head of every resus bed.
Chris
Looks great. I have already created the local version for my shop. Will flick it to you for interest’s sake. Had to alter a few things due to drug and practice variability, but essentially it is the same. Thanks mate. Looking forward to seeing it in action. Ours will be printed on card and pre-folded and taped to the plastic packaging of each airway tray in our resus bays so that you can’t fail to see it when readying for a tube.
Domhnall, what program did you use to customize?
Hey Scott – I tried PDF Expert but couldn’t get it to look nice to generated from scratch. Like I said, I changed heaps – not because I disagree but because local drugs and practice vary some, and I have to keep some old-timers happy. Eg, for non American’s the Cric Con phrase just doesn’t work here, we don’t have etomidate, hydro morphine, etc.
That was meant to read “so I generated it from scratch” and “hydromorphone”
Great checklist Scott. One question on dosing of paralytic in the hypotensive patient. I see the recommended dosing increases for hypotension. Why is this?
Time until effect of muscle relaxants is markedly delayed with decreased CO. Only way to overcome this is to give more.
Hi Scott. Love the checklist and summary of all Pearls Airway. I will plan to incorporate this into my practice, spread it to my ED group and look for its application in Critical Care Transports. Love the podcast, CME site, webtext and your ACEP lectures etc etc. A few first thoughts as I am looking through this in detail. This is more my preference but I like to have people think of bougie as part of 1st attempt so I group them into the routine intubation equipment checklist (vs failed airway). I also like to reinforce using NPA’s + OPA’s… Read more »
I too like bougie on the 1st pass. It is always at the bedside for my intubations. I brought NPA to the front. No need for separate ramping note for high BMI, the positioning is the same for all. Face plane parallel and ears to notch forces ramping in the fatties. Changed hockey stick terminology. CricCon 3 is your double set-up and is on the sheet. Thanks for the additions!
Thanks. Any consideration for the mnemonics/reminder lists for difficulties in DL, VL, SGA and surgical? It could potentially be a checklist to ensure one is choosing the optimal airway technique in the planning stage for the stable patient (eg check mouth, difficulty for BVM and SGA then caution for RSI). It does start to get unwieldy if you add too much, or maybe on the back notes although that is pretty full already too.
Don’t find those lists of predictors to be useful. Assume any airway you do may be unexpectedly difficult to intubate, place an lma, mask, and cric.
Agree that they do not help to rule out difficulty: not sensitive enough so all airways must be assumed to be unexpectedly difficult and plan for failure always. However I do think that predictors can help one structure and plan out (especially the novice and if there is time) what airway approach is best and what plans A, B, C or D might be. E.g. If surgically inevitable and approaches from the mouth and nose are too difficult, improbable or impossible, then perhaps plan A should be cric or CricCon3/double setup. I guess this is actually just basic airway assessment… Read more »
Hey Scott amazing stuff. You have worked so hard to help us do better and for that I clap very loud for your Sir. I know you have tried to help me in the past with printing this out front and back for the first two pages, but it’s just not working out. So the second page prints out long ways and the boxes are 6″ wide by 2.5″ tall. Perfect size. But when I print out the first page the entire text is roughly 7 & 3/4″ wide. Sorry I’m being such a pain in the ass, but this… Read more »
Matt,
Here is a 3×5 version of the checklist.
http://dl.dropbox.com/u/220032/Intubation%20Checklist%203×5.pdf
Beyond that, you need to get creative with the print settings dialog of whatever image program you use on your computer. I use irfanview.
Okay thanks Scott. Does the program you use change PDF files?
ML
Also, I echo your thought to add look in mouth as part of checklist. Levitan I think tells a story where a guy’s jaws were wired together was combative not cooperative and good thing he looked in the mouth/tried to talk to the patient (as any good doc would)! Minor curiosity: awake intubation has neb lido 4% 5ml@6lpm, I assume that it is a trick to remember 4,5,6? (the podcasts I think said 5lpm but really no diff 5 or 6). By the way I printed it duplex and pdf worked fine as is.
nope npot that smart. 5lpm or 6lpm are both just fine. The 4-5-6 is merely coincidence.
LOL, mb subconscious mnemonic of 456?
Very well done Scott! I have to figure a way of making this (Intubation checklist) work in the pre-hospital setting. Too much great information here to not use it.
Jeff
Hi Scott
An anonymous Canadian provider pointed out to me something about the checklist.
In regard to Awake intubation, it states to consider this if expected difficult airway, anatomically or physiologically. There are details about how to do the awake technique,
However, there really are no details about what your definition is of a difficult airway, at least from an anatomical viewpoint. I assume you are leaving up to the intubator to judge based on experience?
so the question is how does a novice or occasional intubator decide when to proceed with an awake intubation, based on the checklist?
For the purposes of the sheet it is all gut. We can do a podcast about the factors that build into this gut feeling.
Thanks Minh, but no need for anonymity. I don’t mind putting my name to the comments, in the spirit of FOAM. I highly value both yours and Scott’s comments. I also appreciate Scott saying that gut feeling is more reasonable than mnemonics in the heat of battle. I’m still in the midst of trying to introduce alternatives like awake intubation, DSI, double setup, etc to my peers, and frankly still fighting an uphill battle to convince my intensivist colleagues that paralytics are safest for most cases. I guess I’m just longing for a decision tool that helps teach the gestalt… Read more »
I agree: my brain won’t retain anything beyond LEMON. I am still struggling to find an easy reliable way to remember, teach and use airway decision making. Currently I like looking for difficulty in anatomy, disrupted airway (bullets bites burns blood bodies (adopted from @emupdates)) and difficult physiology as in HOp and ICP/vascular. (Thanks Scott for that amongst everything else). I would love to hear/discuss/learn more of what goes into gut decision of best airway approach. EMCRIT podcast would be great.
Great work Scott. I am going to teach this to my residents at Monday Morning Report. 2 comments- 1. I put the checklist on my iPad but the second page keeps on turning on its side when I turn it up to look at it straight. Therefore I cannot look at it straight nor use my iPad to teach it. I use Notability. Do you know a fix or alternative app? With the fiscal cliff and budget impasse they repair Army printers a lot slower than they used to… 2. Do you plan to study and validate this per Pronovost… Read more »
re the iPad issue…if you double click the home button it should bring up a horizontal list of recently opened apps. Swipe to the right and tap the icon all the way to the right. The text at the bottom of your screen should say “Portrait Orientation Locked” and the icon will change. Tap the screen or press the home button again to return to normal operation. Now your iPad will not rotate when you turn it on its side. (Just repeat the process to get it back to the way it was.) The same process works with iPhone.
Mobile device friendly version of the checklist is at emcrit.info
I trained 6 residents with the checklist this AM. We went through every item then did an in situ sim case. The scenario was a COPD patient with housefire exposure. This being our first use, it took 8 minutes from EMS report until checklist completion. There’s a lot to do to make a safe intubation.
One of the residents liked it so much he’s going to use it for his QI project and train the entire residency starting with a GR talk then sim for everyone. We’ll probably get some interprofessional play as well.
Thanks for the mobile version.
fantastic. please tell him to get in touch with me if he comes up with anything he thinks can be improved.
Hi Scott,
Excellent work. As a HEMS doc i am really used to checklists and love your efforts – definitely keen to adapt for local use.
One thing i have learnt from aircraft emergency drill books is the importance of using colour. The designers of these checklists use colour to highlight certain points and increase the ease of use on the eye during high demand processes. Do you have a sexy multicoloured version? There is too much grey here in the UK!
Great synopsis of how it should be done though. Thanks
Chris.
I have not gone that direction b/c I want people to be able to print it easily. I had not seen color in many of the aeronautic checklists either. Do you have an example of a checklist that makes great use of color that I could see?
Scott
As always- great stuff and something I can instantly use on my next shift.
My one question- for awake intubations you say to use “ketamine heavy” ketofol. Just curious what your thought process is behind that. Less hypotension from less propofol?
less resp. depression
Great, stuff. I was wondering if you have a good reference on the dosages for your RSI drugs. We are working through standardizing our sedatives and paralytics and need some good references for the dosages. I’m sure I’m missing the data of pubmed, but I can’t seem to find something really convincing.
Great post Scott. Very useful! I miss one thing that is emphasised in our system (university hospital in Norway): Back here its the anestestist that handle all advanced airway management ( ER, OR, ICU), and in a presumed difficult airway case, we would always consider taking the patient to the OR for securing the airway. Of course if time to it. That is generally our most familiar environment with the OR team, ventilators, good light and the setup we are using all day. I guess your most familiar environment is the ER, but in many systems it will be another… Read more »
Question: do you view HOp kills much differently from how ICP/Vascular problems might also potentially kill too? Catecholamine/ sympathomimetic concerns like high ICP, ICH (including hypertensive ecclampsia needing intubation), SAH, Ao diss, cardiac ischemia being amongst my worries. The way I am seeing it in my head is to bundle HOp kills and catecholamine driven bad effects of intubation together (CHOp kills?). Trying to see why ICP/Vasc is separated out along with RSI/DSI/RSA/Awake. Think you said a podcast on it is pending? Question 2: Do you think adding strategies to intubation/post-intubation management of status asthmaticus or status epilepticus for the… Read more »
1.
I think about these two a little differently. The ICP/Vascular requires a bunch of prep time and while it can make matters worse generally doesn’t cause cardiac arrest (though I guess a ruptured AD may be pretty bad.) The key difference is that if you need to intubate NOW, the ICP/Vascular stuff gets shunted aside.
2.
Post-intubation for asthma is on there, other strategies are another checklist.
Thanks: HOp is a nice fast short list to use too … poetry!
I’m having thoughts of adapting/using this for procedural sedation analgesia … maybe the whole package is not required for the routine healthy person for orthopedic reduction, however, much of the checklist is helpful for the other extreme of PSA like the sick emergent cardioversion who might have borderline BP or sats. Great to have checklists like this when doing high acuity low frequency procedures.
My coworker, @emupdates, has a PSA protocol
http://emupdates.com/2011/05/08/procedural-sedation-and-analgesia-checklist/
it is pretty great. though the two of us differ on a few things like ketofol
Another thought for the checklist (unless I missed it) is dosing for morbid obesity … succinylcholine is per total body weight versus propofol and rocuronium is per ideal body weight. Ketamine I have seen as being per lean body weight or ideal body weight. Etomidate I have seen one source say per total body weight (Annals EM 56:2, 2010) and another as per lean body weight (Br J Anes 105:suppl 1 2010). What do you use?
For paralytics, I would always err on the side of too much rather than too little, so I ignore the roc. IBW and just do TBW for both. For sedatives I don’t care as much b/c I am dosing based on gestalt. Here are Strayer’s choices.
In the equipment box: failed airway equipment at bedside – should probably add a smaller ETT like a 6.0 or 6.5 for a bougie aided cric.
Great work Scott
brilliant. just added it!
Really enjoyed this too… going to look at trial of a roll out in my simulations with the ER residents at University of Ottawa. will let you know how it goes.
Hey there Dr. Weingart, I think the checklist is a great tool for intubation and I applaud your desire to continually tweak and improve it, just like they do all the time for aviation checklists. While I think that something like emergency ET intubation is something that requires a dedicated checklist, there are things we do all the time that should require a 30 second briefing (I hate the phrase “time out”) that we blow past. It’s in the same vein as how we probably underutilize sedation for common painful proceedures. I’ve attached a standardized prompt that my boss Ken… Read more »
Amazing Comment
I will use this stuff for a future post.
Nice!
When do you think we unfortunate souls who weren’t able to make it to SMACC will be able to hear you talk about intubating the hemodynamically unstable patient?
soon
Hi Scott
dealt with a difficult Airway during my last shift..I failed twice (oesophagus) and eventually one go colleagues did it…There was a lot of confusion about the position whether its in esoph or trachea. Since we do not have wETCO2 in our ER, So I was wondering if we can confirm the tube placement by inserting a bougie into the tube and feel for tracheal rings before we start bagging!!
lakshay
INDIA
Feeling rings won’t work. You can gently pass the bougie to find hold-up. The confusion is natural it is why ETCO2 became a requirement in all operating rooms in the USA.
You need ETCO2
Do you have access to USS? Watching the ETT pass into trachea might be an alternative
But ETCO2 is the standard. Use it.
Wow, awesome site. Im a 4th year med student, came across this site searching for HINTS tests for constant vertigo, i came across these amazing site. Im at hennepin county in minnesota for an ER rotation, and saw a vertigo pt. this blog was so helpful. Now im watching random vids, thanks so much for the amazing work.
Great podcast, as always. The program/app you use is perfect for presentations on checklist and protocols? What is it?
One suggestion: since a member of the team is being dedicated for SpO2, he might as well check for BP & hemodynamics during the periintubation period.
Do you mean the video? If so, the program is called “explain everything”; it is an ios app.
Hey Scott, It makes sense that in a low CO state two things would be true: #1. Much lower dose of a med is required #2. Onset of med will take longer With respect to the sedative- we drastically reduce the dose (#1), so as not to flood the pt with a relative overdose that would further compromising hemodynamics. With respect to the paralytic, I assume #1 is still true, except we don’t really care about relatively “overdosing”, and so we address #2 by increasing the dose to shorten onset time. However, I would also assume that #2 still holds… Read more »
ketamine, etomidate, and propofol are all single pass meds. Ketamine will have taken effect within one circulation time–this will not be sig. altered even in shock state so long as there is any blood flow.
Scott,
This is beautiful but is there any chance of making a black and white version without the shading and normal fonts? It doesn’t print nice on my generic black and white printer at home. Not sure how it does on hospital BW laser printers. Just a thought. Thanks for your work and time.
Has anybody seen a study that actually shows improved outcomes using paralytics as opposed to not?
Has anybody seen a patient cough after getting Ketamine or Etomidate?
Jim Jones in Texas
Jim, there is an entire debate on the site on this topic
Hello Scott
Just wondering if elevation of bed to an angle around 30 degree ,will give better view of the cords during intubation and make it easier or not ?
yes
article in Br J Anesth proves it. You can find the actual ref in my preox article at emcrit.org/preox
Not to be too simplistic, but I would add “vent” to the equipment list in your protocol. In the heat of the moment it’s entirely possible for everyone to forget the ventilator. I don’t suppose you really have to ask how I know. In fact more than once we have progressed nearly to the point of intubation and discovered that everyone assumed someone else had called RT. Not sure how that would fit in the protocol as it seems so obvious. Yet “obvious” has different meaning in the heat of the moment vs the cold light of day. In the… Read more »
Hi Scott and folks, do you think this same RSI sequence should work in an ICU or this is only in the ED? The critical care population may be a bit different sometimes, so I dont know if the evidence for RSI applies there (https://www.ncbi.nlm.nih.gov/pubmed/24259635) Best! Fede
Nice video. just a few observations based on seeing the video. First of all double glove or triple glove that way you can peel off a layer without getting yuk on everything. but leave the base layer as you can’t get gloves on sweaty hands. Positioning is key I like the patient to be all the way up to the head of the bed. Especially in a patient in a big ICU bed you can create position where you are hanging off the end prone and that is just unnecessarily complicating things on a one shot one kill mission (… Read more »
Dr Weingart, thank you.
I’d like to share some specifics but I think the patient I dealt with which you helped me the most is rare enough and recent enough that HIPPA would be violated if I discussed it.
Great checklist Scott!!